Isabella Rosa

Impact and evolution of right ventricular dysfunction after successful MitraClip implantation in patients with functional mitral regurgitation

Background Right ventricular dysfunction (RVdysf) is a predictor of poor outcome in patients with heart failure and valvular disease. The aim of this study was to evaluate the evolution and the impact of RVdysf in patients with moderate–severe functional mitral regurgitation (FMR) successfully treated with MitraClip. Methods and results From October 2008 to July 2014, 60 consecutive high surgical risk FMR patients were evaluated and stratified into two groups: RVdysf group (TAPSE < 16 mm and/or S′TDI < 10 cm/s, 21 patients) and No-RVdysf group (38 patients). The overall mean age of patients was 73 ± 8 (83% male). Ischemic FMR etiology was present in 67%. Mean LVEF was 30 ± 10%. Overall mean time follow-up was 565 ± 310 days. The only significant difference between the two groups was a greater prevalence of stroke, ICD and use of aldosterone antagonist in RVdysf group. Acute procedural success was achieved in 90% of patients. At 6-month echo-matched analysis significant RV function improvement was observed in patients with baseline RVdysf (TAPSE 15 ± 3.0 vs. 19 ± 4.5, p = 0.007; S′TDI 7 ± 1.2 vs. 11 ± 2.8, p < 0.0001; baseline vs. 6-month, respectively). The mean improvement in the 6-min walking test was significant in both groups (120 and 143 m, RVdysf and No-RVdysf groups, respectively). At Kaplan–Meier analysis, the presence of RVdysf did not affect the outcome in terms of freedom from composite efficacy endpoint. Conclusions This study shows that successful MitraClip implantation in patients with FMR and concomitant right ventricular dysfunction yields significant improvement of RV function at mid-term follow-up. Further data on larger population will be required to confirm our observations.

Role of plaque calcification regulators osteoprotegerin and matrix Gla-proteins in stable angina and acute myocardial infarction

Aim To assess serum levels of the plaque calcification regulators osteoprotegerin (OPG) and Matrix Gla-proteins (MGP) in individuals with stable angina and acute myocardial infarction submitted to coronary angiography and their relation to coronary artery disease burden. Methods The study included 40 individuals affected by ST-elevation myocardial infarction (STEMI) and 40 individuals with stable angina who all underwent coronary angiography, with evaluation of the extent of coronary artery disease by Syntax Score calculation and measurement of serum OPG and MGP levels. Osteoporosis was excluded by femoral and vertebral computerized bone mineralometry. Results Serum OPG and MGP levels were respectively 3.87 ± 1.07 pmol/l and 6.80 ± 2.43 nmol/l in the stable angina group, 7.57 ± 1.5 pmol/l and 7.18 ± 1.93 nmol/l in the STEMI group (P < 0.01 and P = 0.33, respectively). Pearson correlation coefficient for OPG and Syntax Score, MGP and Syntax score was respectively 0.79 (P < 0.01) and 0.18 (P = 0.22) in the stable angina group, −0.03 (P = 0.43) and 0.10 (P = 0.5) in the STEMI group. Serum OPG and MGP levels were respectively 5.52 ± 1.02 pmol/l and 7.56 ± 1.42 nmol/l in diabetics, 4.3 ± 0.8 pmol/l and 6.52 ± 1.14 nmol/l in nondiabetics (P < 0.05; P < 0.05). Conclusion OPG, in a relatively small group of patients with stable angina, correlates proportionally with the extent of coronary artery disease (CAD), as evaluated by the Syntax Score. Higher serum OPG levels can be observed in individuals with STEMI regardless of CAD burden. As for MGP, a potential role as marker of plaque calcification remains unproven.

Unrepaired tetralogy of fallot in an 85-year-old man.

Tetralogy of Fallot is the most common cyanotic congenital heart defect and accounts for about 5% of all congenital cardiopathies. The definitive treatment modality for tetralogy of Fallot is reparative surgery, which is recommended to be performed by the time of diagnosis. Without surgical repair, most patients would die during their childhood. In the past, survival data indicated that 66% of persons with tetralogy of Fallot not surgically treated lived until the age of 1, 49% lived until the age of 3, and 24% lived until the age of 10. We now present a rare case of a man with unrepaired tetralogy of Fallot who survived until the age of 85. He presented to our emergency room for dyspnea and palpitations due to a new-onset high-frequency atrial fibrillation and acute heart failure; transthoracic echocardiography showed the presence of tetralogy of Fallot. By consulting the scientific literature, we can say that this is the second patient who survived more than 80 years without surgical intervention.

Use of Echocardiography for Guiding Percutaneous Tricuspid Valve Procedures

Percutaneous tricuspid valve (TV) repair procedures are emerging therapies for patients with symptomatic severe tricuspid regurgitation (TR) who are deemed inoperable. Some of these procedures target the tricuspid annulus (TA), mimicking the Kay procedure, or the leaflets, mimicking Alfieri stitch

PFO closure with only fluoroscopic guidance: 7 years real-world single centre experience

To evaluate the safety and the efficacy of fluoroscopy‐guided only (Fluo‐G) and of echocardiography‐guided (Echo‐G; trans‐esophageal echocardiography—TEE—or intracardiac echocardiography‐ICE) percutaneous closure of patent foramen ovale (PFO).

Echocardiographic features of post-transcatheter aortic valve implantation thrombosis and endocarditis.

Transcatheter heart valve thrombosis (THV‐t) and endocarditis (THV‐e) are relevant complications after transcatheter aortic valve implantation (TAVI). Transcatheter heart valve (THV) dysfunction definition is mostly based on Doppler (stenosis/regurgitation) without considering leaflets characteristics.

Mechanical dyssynchrony and deformation imaging in patients with functional mitral regurgitation

Chronic functional mitral regurgitation (FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy (DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in FMR, such as annular dilatation and dysfunction, left ventricle (LV) remodeling, dysfunction and dyssynchrony, papillary muscles displacement and dyssynchrony. The best therapeutic choice for FMR is still debated. When optimal medical treatment has already been set, a further option for cardiac resynchronization therapy (CRT) and/or surgical correction should be considered. CRT is able to contrast most of the pathophysiologic determinants of FMR by minimizing LV dyssynchrony through different mechanisms: Increasing closing forces, reducing tethering forces, reshaping annular geometry and function, correcting diastolic MR. Deformation imaging in terms of two-dimensional speckle tracking has been validated for LV dyssynchrony assessment. Radial speckle tracking and three-dimensional strain analysis appear to be the best methods to quantify intraventricular delay and to predict CRT-responders. Speckle-tracking echocardiography in patients with mitral valve regurgitation has been usually proposed for the assessment of LV and left atrial function. However it has also revealed a fundamental role of intraventricular dyssynchrony in determining FMR especially in DCM, rather than in ischemic cardiomyopathy in which MR severity seems to be more related to mitral valve deformation indexes. Furthermore speckle tracking allows the assessment of papillary muscle dyssynchrony. Therefore this technique can help to identify optimal candidates to CRT that will probably demonstrate a reduction in FMR degree and thus will experience a better outcome.

Successful transradial removal of an inflated coronary stent dislodged from the right coronary ostium

We describe our solution to the unusual situation of an inflated, large coronary stent (3.5 mm diameter) which became dislodged from the ostium of the right coronary artery after deployment during a transradial procedure. We discussed tips for retrieval from the radial artery while preserving the access for completion of the procedure.

Accuracy and reproducibility of aortic annular measurements obtained from echocardiographic 3D manual and semi-automated software analyses in patients referred for transcatheter aortic valve implantation: implication for prosthesis size selection

Aims A 3D transoesophageal echocardiography (3D-TOE) reconstruction tool has recently been introduced. The system automatically configures a geometric model of the aortic root and performs quantitative analysis of these structures. We compared the measurements of the aortic annulus (AA) obtained by semi-automated 3D-TOE quantitative software and manual analysis vs. multislice computed tomography (MSCT) ones. Methods and results One hundred and seventy-five patients (mean age 81.3 ± 6.3 years, 77 men) who underwent both MSCT and 3D-TOE for annulus assessment before transcatheter aortic valve implantation were analysed. Hypothetical prosthetic valve sizing was evaluated using the 3D manual, semi-automated measurements using manufacturer-recommended CT-based sizing algorithm as gold standard. Good correlation between 3D-TOE methods vs. MSCT measurements was found, but the semi-automated analysis demonstrated slightly better correlations for AA major diameter (r = 0.89), perimeter (r = 0.89), and area (r = 0.85) (all P < 0.0001) than manual one. Both 3D methods underestimated the MSCT measurements, but semi-automated measurements showed narrower limits of agreement and lesser bias than manual measurements for most of AA parameters. On average, 3D-TOE semi-automated major diameter, area, and perimeter underestimated the respective MSCT measurements by 7.4%, 3.5%, and 4.4%, respectively, whereas minor diameter was overestimated by 0.3%. Moderate agreement for valve sizing for both 3D-TOE techniques was found: Kappa agreement 0.5 for both semi-automated and manual analysis. Interobserver and intraobserver agreements for the AA measurements were excellent for both techniques (intraclass correlation coefficients for all parameters >0.80). Conclusion The 3D-TOE semi-automated analysis of AA is feasible and reliable and can be used in clinical practice as an alternative to MSCT for AA assessment.

P1246Age-, body size-, and sex-specific reference values for tricuspid valve apparatus parameters by real-time three-dimensional transthoracic echocardiography

Background and Purpose-Tricuspid valve (TV) apparatus parameters can vary significantly with demographic and anthropometric factors and could be useful for clinical decision making. Our aim was to (1) establish the reference values for TV apparatus parameters using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on TV anatomy. Methods-A total of 180 healthy subjects referred in 2015 to our institution for a screening transthoracic echocardiography were enrolled (mean age 49.7+17.4 years, range 20 to 80 years: 30 subjects per age decade were included in the study, 15 for each gender). A real-time zoom 3D image of the TV and full volume 3D data set were collected from an apical window including TV using Philips iE33 and GE Vivid E9 Ultrasound Machines. After acquisition, the 3D data sets were analysed using 3D Qlab and EchoPAC PC softwares. The volumetric data set was analysed with multiplanar reformatting function to obtain three simultaneous orthogonal 2D slices (sagittal, coronal and axial planes). The following TV parameters were obtained and measured: 1. the 3D diastolic annular diameters (Major and Minor diameters); 2. the 3D diastolic annular area (TDAA); 3. the Tricuspid annular fractional area changes (TAFAC). Results are presented as mean ± SD. Differences between and among groups were tested for significance using the independent samples t-test and ANOVA test for continuous variables. Univariate Pearson correlation was used to assess the relation between these parameters and age, and body size. A p <0.05 was considered significant. Results- Minor and major diastolic diameters in overall population were 26.1±3.9 and 32.3±4.1 mm, respectively. Minor diastolic diameter (mDD) (26.9±4.2 vs 25.1±3.4 mm, p <0.05) and major diastolic diameter (MDD) (33.4±4.0 vs 30.9±3.8, p <0.05) were significantly different between males and females. After normalization for BSA, mDD and MDD in overall population were 14.6±2.2 and 18.3±2.3 mm/m2. Normalized mDD (14.3±2.3 vs 14.9±2.2 mm/m2, p >0.05) and normalized MDD (18.1±2.4 vs 18.4±2.3 mm/m2, p>0.05) did not differ significantly between males and females. TTDAA and TAFAC in overall population were 76.7±17.3 mm2 and 29.6±8.6%. TDAA was significantly different between males and females (82.5±18.3 vs 69.7±13.0 mm2, respectively; p < 0.05); whereas TAFAC did not differ (28.8±8.2% vs 30.7±8.9%, p>0.05). After normalization for BSA, TDAA in overall population was 43.3±9.0 mm2/m2. Also normalized TDAA was significantly different between males and females (44.4±9.4 vs 42.0±8.4 mm2/m2, p < 0.05). mDD, MDD, TDAA and TAFAC showed no correlation with age (r = 0.16, p 0.04; r = 0.028, p 0.7; r = 0.17, p 0.27; r = 0.16, p 0.16; respectively). Conclusion- This study can provide normal reference values for TV anatomic parameters that may be useful in the clinical practice, considering the effects of age, sex, and body size.